Failure to Provide Ordered Assistive Eating Device
Penalty
Summary
The facility failed to provide a required assistive meal device, specifically a divided plate, for a resident with significant medical needs. The resident had a history of metabolic encephalopathy, malnutrition, dysphagia, and cognitive communication deficit, and was assessed as cognitively impaired. Medical records, care plans, and a communication order all indicated that the resident required a divided plate at every meal to support independent eating. The resident's meal information card also specified the need for a divided plate. Despite these documented requirements, observations on two separate occasions showed that the resident was served meals on a regular plate rather than the prescribed divided plate. Staff interviews confirmed that the resident needed the divided plate to promote independence with meals, and facility leadership acknowledged that the assistive device was not provided as ordered during the observed meals.